New Prescriber Registration Form

MedQuest New Prescriber Registration Form

Business Name*

Office Phone	Office Fax

Cell Phone*

Office Contact

DEA #	License #

NPI #

Credentials

Other

Specialty

Currently Practicing BHRT?

Yes

Expect to begin practicing BHRT?

Yes

Expected start date

Pharmacy Preferences

eMedPlus Account Setup

Custom Rx Pads

Starter Kit

Marketing Kit

Laboratory Testing Preferences

Lab Acct Setup

Results Fax

Results Email

Kit to Office

Kit to Patient

Are your plans to BHRT exclusively or incorporate into your practice?

What are the biggest challenges or roadblocks in moving forward?

What are the top offerings/services/elements most important to you?

What would the ideal, perfect compounding pharmacy offer you?

What do you need help with to be successful with BHRT?

Do you have a best practice you would like to share with other health care professionals?

Would you like to refer any colleagues to MedQuest Pharmacy?

Referral Phone Number